Appendix B: Waiver NY .0034.R06.02 - Jul02,20 12
Page 1 of 24
Appendix B: Participant Access and Eligibility
B-1: Specification of the Waiver Target Group(s)
a. Target Group@). Under the waiver of Section 1902(a)(lO)(B) of the Act, the State limits waiver services to a group or
subgroups of individuals. Please see the instruction manual for specifics regarding age limits. In accordance with 42
CFR $441.301(6)(6), select one waiver target group, check each of the subgroups in the selected target group that may
b minimum and maximum (if any) age of individuals served in each
receive services under the waiver, and s p e c ~ the
subgroup:
Target Group
Included
Target SubGroup
Minimum Age
Maximum Age
Maximum Age No Maximum Age
Limit
Limit
-
Aged or Disabled, or Both General
Aged
65
Disabled (Physical)
0
64
Disabled (Other)
Aged or Disabled, or Both - Specific Recognized Subgroups
Rrain lnjury
IIlV/AIDS
Medically Fragile
Technology Dependent
Mental Retardation or Developmental Disability, or Both
Autism
1)evelopmental Disability
Mental Retardation
Mental Illness
Mental Illness
Serious Emotional Disturbance
b. Additional Criteria. The State further specifies its target group(s) as follows:
Individuals who are diagnosed by a physician as having AIDS, infected with the etiologic agent of AIDS, or who have
an illness or disability attributable to such infection are a subgroup of the LTHHCP. This subgroup is referenced as
the AIDS Home Care Program (AHCP).
c. Transition of Individuals Affected by Maximum Age Limitation. When there is a maximum age limit that applies
to individuals who may be served in the waiver, describe the transition planning procedures that are undertaken on
behalf of participants affected by the age limit (select one):
Not applicable. There is no maximum age limit
The following transition planning procedures are employed for participants who will reach the
waiver's maximum age limit.
In the LTHHCP, the transition is invisible to the participant between this waiver application catigorization
between individuals with disabilities (0-64) and individuals 65 and over. The available services and program
processes remain the same.
Appendix B: Waiver NY.0034.RO6.02 - Jul02,2012
Page 2 of 24
Appendix B: Participant Access and Eligibility
B-2: Individual Cost Limit (1 of 2)
a. Individual Cost Limit. The following individual cost limit applies when determining whether to deny home and
community-based services or entrance to the waiver to an otherwise eligible individual (select one) Please note that a
State may have only ONE individual cost limit for the purposes of determining eligibility for the waiver:
No Cost Limit. The State does not apply an individual cost limit. Do not complete Item B-2-b or item B-2-c.
Cost Limit in Excess of Institutional Costs. The State refuses entrance to the waiver to any otherwise eligible
individual when the State reasonably expects that the cost of the home and community-based services furnished to
that individual would exceed the cost of a level of care specified for the waiver up to an amount specified by the
State. Complete Items B-2-6 and B-2-c.
The limit specified by the State is (select one)
A level higher than 100% of the institutional average.
Specify the percentage:
Other
R
r-3
t :.,l
Institutional Cost Limit. Pursuant to 42 CFR 441.301(a)(3), the State refuses entrance to the waiver to any
otherwise eligible individual when the State reasonably expects that the cost of the home and community-based
services furnished to that individual would exceed 100% of the cost of the level of care specified for the waiver.
Complete Items B-2-b and B-2-c.
Cost Limit Lower Than Institutional Costs. The State refuses entrance to the waiver to any otherwise qualified
individual when the State reasonably expects that the cost of home and community-based services furnished to
that individual would exceed the following amount specified by the State that is less than the cost of a level of
care specified for the waiver.
Specrfi the basis of the limit, including evidence that the limit is suficient to assure the health and welfare of
waiver participants. Complete Items B-2-b and B-2-c.
The cost limit specified by the State is (select one):
The following dollar amount:
Specify dollar amount:
The dollar amount (select one)
Is adjusted each year that the waiver is in effect by applying the following formula:
Specify the formula:
May be adjusted during the period the waiver is in effect. The State will submit a waiver
amendment to CMS to adjust the dollar amount.
The following percentage that is less than 100% of the institutional average:
Page 3 of 24
Specify percent:
Other:
Specifi:
Appendix B: Participant Access and Eligibility
B-2: Individrlal Cost Limit (2 of 2)
b. Method of Implementation of the Individual Cost Limit. When an individual cost limit is specified in Item B-2-a,
specify the procedures that are followed to determine in advance of waiver entrance that the individual's health and
welfare can be assured within the cost limit:
In the LTHHCP, the LOC assessment is determined in advance of waiver participation by use of the New York State
Long Term Care Placemnt Form Medical Assessment Abstract (DMS-I), or the Pediatric Patient Review Instrument
(PPR1)for individuals under the age of 18, which assesses the medical and functional needs of an individual. In
addition, a comprehensive assessment of an individual's medical, functional, psychosocial, and supportive needs is
completed, which along with the Home Assessment Abstract (HAA) consolidates all of the assessed needs and
strengths. This may also identify safe substitutes which are more cost effective services such as the use of assistive
technology devices, e.g. grab bars in a bathroom, a one time ramp installation or Meals on Wheels as opposed to extra
Personal Care hours for food preparation, along with utilizing informal supports. These efficiencies allow for an
individual to maintain independence while enhancing their strengths and allowing for their needs to be met.
This assessment provides a Summary of Services which the individual requires to be maintained safely and leads to
the plan of care. The Summary of Services includes all services, including waiver services and informal supports. A
proposed budget is developed from the Summary of Services accounting for the assessed needs and all payor
sources.
The LTHHCP utilizes what is known as an annualized budget. The annualized budget is the result of the process by
which the costs of care for an individual are averaged over the year so that care costs that may exceed the expenditure
cap in one or more months do not limit the use of the LTHHCP. The intent of the annualized budget is to encourage
the use of the LTHHCP when it can be reasonably anticipated that the total Medicaid expenditures for a 12-month
period will not exceed 100% of the average nursing facility rate in the individual's county of residence.
The individual's LTHHCP expenditure cap is calculated at 75% of the average nursing facility rate in the individual's
county of residence; however, LTHHCP services may be provided to persons with special needs, up to 100% of the
averagc nursing facility rate in the county of residence. If an individual is a resident of an Adult Care Facility (ACF),
their expenditure cap is 50% of the average nursing facility rate in the individual's county of residence, which
accounts for services provided by the ACF.
c. Participani Safeguards. Wn~cnthe State specifies an individual cost limit in Item B-2-a and there is a change in thc
participant's condition or circumstances post-entrance to the waiver that requires the provision of services in an amount
that exceeds the cost limit in order to assure the participant's health and welfare, thc State has established the following
safeguards to avoid an adverse impact on the participant (check each that applies):
The participant is referred to another waiver that can accommodate the individual's needs.
Additional services in excess of the individual cost limit may be authorized.
Specify the procedures for authorizing additional services, including the amount that may be authorized:
LTHHCP participants also have the option to accumulate paper credits. Monthly paper credits may be
accumulated and used at a later date if service needs exceed the expenditure cap. A paper credit is the difference
between the costs of Medicaid services utilized in a month and the applicable expenditure cap. If the individual
uses services in an amount less than the expenditure cap for a given month, a paper credit is accrued. When
calculating paper credits, a look back period is used to determine available credit, using only the previous I I
months and the current month. Previous unused paper credits, prior to the 11 month period, are not available for
use. The LDSS is responsible for tracking and autliorizing use of paper credits which can be used in the event of
a period of higher service needs.
Appendix B: Waiver NY.0034.RO6.02 - Jul02,2012
Page 4 of 24
Both paper credits and annualization of the budget are effective in addressing a participant's fluctuations in
hisher needs. In addition, LDSS staff and LTHHCP agency staff consider other means of maintaining the
budget within the limit, including: maximization of third party resources; increased use of informal supports
including community social services andlor family; and service substitution. For example, it may be possible to
use the waiver service of "moving assistance" to relocate a participant closer to a family member; the family
member is then able to provide informal support on a more frequent basis lowering the participant's budget for
paid assistance. Alternatively, initiating attendance at adult day health care may be a more cost effective means
of providing coordinated services. Each case is unique and requires discussion with the participant about hidher
options and choices.
The cost limit is not adjusted if an individual participant exceeds hisher paper credit amount. However, within
the cost limit, safeguards do exist to maximize the participant's ability to be served by the waiver
These credits may be used for:
o Additional services following the exacerbation of an illness
o Increased service needs due to caregiver illness or absence
o Equipment purchases
o Other needs which are identified in the plan of care
Participants are informed of and referred to other options as necessary. In New York State, this can include the
range of existing State Plan home care services as well as other available 191% waivers such as the Nursing
Home Transition and Diversion Waiver.
Other safeguard(s)
Specify:
zz
F'--I
f.. ..'I
Appendix B: Participant Access and Eligibility
B-3: Number of Individuals Served (1 of 4)
a. Unduplicated Number of Participants. The following table specifies the maximum number of unduplicated
participants who are served in each year that the waiver is in effect. The State will submit a waiver amendment to CMS
to modify the number of participants specified for any year(s), including when a modification is necessary due to
legislative appropriation or another reason. The number of unduplicated participants specified in this table is basis for
the cost-neutrality calculations in Appendix J:
1
..-.
,..
I-
--.,.--
me.-v
Waive~.Year
-
Tab!S@-a
-.,.,.--
Number of
p y y
I
--
- -
.
..
.
..
.---
-.s:L-s
Year 5
,----.-*.-.>
-..---~,%
.--..-*.m*.--=.:.-~-~.
.-
<
..
.-.
,-
~
22349
-.
,
~..-.
~.
23
-".320
.-
.
-...
,. %7-r.:.
:::::
._^Y..:.
_
150 1
.
I
t ~ ~l r : k i ; ~ l
4
1-
.~----.,'.c.
--_.
I
.
.
b. Limitation car? the Number of Participants Sewed a t A.ny Point il-n Time. Consistent with thc unduplicated number
of participants specified in Item B-3-a, the State may limit to a lesser number the number of participants who will be
served at any point in time during a waiver year. Indicate whether the State lirnits the number of participants in this
way: (select one):
The State does not limit the number of participants thst it serves a t any point in time during a waiver
year.
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Page 5 of 24
Appendix B: Waiver NY.0034.RO6.02 - Jul02,2012
The State limits the number of participants that it serves at any point in time during a waiver year.
The limit that applies to each year of the waiver period is specified in the following table:
Table: B-3-b
Waiver Year
Maximum Number of Participants
Served At Any Point During the Year
Year 1
-
Year 3
Year 4
Year 5
*b
ytili
B-3: Number of Individuals Served (2 of 4)
c. Resewed Waiver Capacity. The State may reserve a portion of the participant capacity of the waiver for specified
purposes (e.g., provide for the community transition of institutionalized persons or furnish waiver services to
individuals experiencing a crisis) subject to CMS review and approval. The State (select one):
Not applicable. The state does not reserve capacity.
The State resewes capacity for the following purpose(s).
Appendix B: Participant Access and Eligibility
B-3: Number of Individuals Served (3 of 4)
d. Scheduled Phase-In or Phase-Out. Within a waiver year, the State may make the number of participants who are
served subject to a phase-in or phase-out schedule (select one):
The waiver is not subject to a phase-in or a phase-out schedule.
The waiver is subject to a phase-in o r phase-out schedule that is included in Attachment #I to
Appendix R-3. This schedule con:stitutes an int~c-yearlirnitabicrr: r n the number- of participants who
are served in thc waiver.
e. Allocction of Waiver Capacity.
Select one:
Waiver capacity is allocated/niaraaged on a statewide basis.
Waiver capacity is allocated to IocaVregional non-state entities.
Specify: (a) the entities to which waiver capacity is allocated; (b) the methodology that is used to allocate capacity
and how often the methodology is reevaluated; and, (c) policies for the reallocation of unused capacity among
local/regional non-state entities:
t ...i
f. Selection of Entrants to the Waiver. Specify the policies that apply to the selection of individuals for entrance to the
waiver:
Appendix B: Waiver NY.0034.RO6.02 - Jul02,2012
Page 6 of 24
In the LTHHCP, evaluations for level of care are provided to all applicants for whom there is reasonable indication
services may be needed. All individuals are assessed for meeting nursing facility LOC upon application for the
program. An individual must elect to participate in the waiver program, and there must be available resources to
assure the health and welfare of the individual within the community.
Appendix B: Participant Access and Eligibility
B-3: Number of Individuals Served - Attachment #1 (4 of 4)
Waiver Phase-InIPhase-Out Schedule
Based on Waiver Proposed Effective Date: 09/01/10
a. The waiver is being (select one):
Phased-in
Phased-out
b. Phase-InIPhase-Out Time Schedule. Complete thefollowing table:
Beginning (base) number of Participants: 22349
Phase-Idphase-Out Schedule
Waiver Year 1
Waiver Year 2
Waiver Yesi. 3
Undoplicr.f:?dNumber of P;?rs"i?'i)ants:2371 1
Waiver Yc::;.
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Appendix B: Waiver NY.0034.RO6.02 - Jul02,2012
Page 7 of 24
Phase-Inphase-Out Schedule
Base Number o f
Participants
Month
Participant
Limit
Change
I
I
I
I
I
May
5389
750
Jun
4639
1500
3139
4639
14356
13606
Jul
3139
1500
1639
13606
12856
Au!Z
1639
1500
139
Waiver Year 5
Month
Participant
Limit
Change
Unduplicated Number of Participants: 1501
Participant
BascNumhcr of
Change
Participants
Limit
0
SCP
139
Dec
139
Jan
139
Mar
139
0
139
A P ~
139
0
139
Jun
139
0
139
Jul
139
0
139
.
139
139
c. Waiver Years Subject to Phase-InIPhase-Out Schedule
I
I
I
Year One Year Two year ~ h r e e Year
l
Four Year Five
rn
d. Phase-InIPhase-Out Time Period
Waiver Year: First Calendar Month
--- -.
Plinsc-in/P[tase-out bcgiln
--...
Phase-in1Phase-out ends
--AT-
-.
Mor~t!?
---
-*-.
.-
>,:.-:--.
, -
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:
.--.-
-
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-,-.
---,-.
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-
I
Waiver Yeer
--:--.---.
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.-....->
Jnz
3
a
I. .
Appendix B: Participaut Access and
Eligibility
-B-4: Eligibility Groups Served in the Waiver
1. State Classification. The State is a (select one):
91634 State
SSI Criterin State
209(b) State
2. Miller Trust State.
Indicate whether the State is a Miller Trust State (select one):
.-.~....",-
4
.
--
. .
=
r
.
-
. .. ..*-. .. . .
Appendix B: Waiver NY.0034.RO6.02 - Jul02,2012
Page 8 of 24
No
Yes
b. Medicaid Eligibility Groups Served in the Waiver. Individuals who receive services under this waiver are eligible
under the following eligibility groups contained in the State plan. The State applies all applicable federal financial
participation limits under the plan. Check all that apply:
Eligibility Groups Served in the Waiver (excluding the special lrome and community-based waiver group under 42
CFR 8435.217)
Low income families with children as provided in $1931 of the Act
SSI recipients
Aged, blind o r disabled in 209(b) states who are eligible under 42 CFR 5435.121
Optional State supplement recipients
Optional categorically needy aged and/or disabled individuals who have income at:
Select one:
100% of the Federal poverty level (FPL)
% of FPL, which is lower than 100% of FPL.
Specify percentage:
Working individuals with disabilities who buy into Medicaid (BBA working disabled group as provided in
§1902(a)(lO)(A)(ii)(XIII)) of the Act)
Working individuals with disabilities who buy into Medicaid (TWWIIA Basic Coverage Group as provided
in §1902(a)(lO)(A)(ii)(Xv) of the Act)
Working individuals with disabilities who buy into Medicaid (TWWIIA Medical Improvement Coverage
Group as provided in §1902(a)(lO)(A)(ii)(XVZ) of the Act)
Disabled individuals age 18 or younger who would require an institutional level of care (TEFRA 134
eligibility group as provided in §1902(e)(3) of the Act)
Medically needy in 209(b) States (42 CFR 5435.330)
Medically needy in 1634 States and SSI Criteria States (42 CFR 5435.320,§435.322 and $435.324)
Other specified groups (include only statutorylregulatory reference to reflect the additional groups in the
State plan that may receive services under this waiver)
Children who qualify under 1902(a)(lO)(A)(i)(IV)of the Social Security Act for infants under one year of age,
1902(a)(lO)(A)(i)(VI)children who have attained one year of age but have not attained six years of age and 1902
(a)(lO)(A)(i)(VII) children who have attained six years of age but have not attained 19 years of age, and children
ciho qualify under 1992(a))(lO)(A)(ii>(VIII)State adoptio:l assistance fo:. children wit11 spcci::! needs. Also
i,:c!::cJed are childrci: ;.!l!o were recc:i.!l;-:l; SSI on Augcs'::?:?, 1996, ancl -::'.:-:
SSI was discci-.:i;:tred due tc : ' :
cliarlge in disability criteria as enacted b;~section 21 1(a) o'i-he Personal Rcsi~onsibilityand K"i.k OppoTtuniLy
Kco;;?ciliation Act oi' 1796 (PROWL'-;. 2ilder the O B f * c;' ;997, these c::i::::;,n
are deerileci is L 2 receiving ZZT :
tir;, cmtinue to meet tile income a d :?r9!r!rce requiremc;::~ for SSI (sect!:. !802(a)(lO)(A)(i)(Il).
. -.-. .-
Special / : ~ m and
e comntunity-based waivei-$oup under ~ ~ C 8435.21
F R 7)1i7Ge: When the special home and
communi(y-based waiver group under 42 CFl? §435.2/ 7 is inclzrded, Appendix B-5 must be cotnpleted
No. Tile State does not furnish waiver services to individuals in the spec:?! home and community-based
waiver group under 42 CFR 9435.217. Appendix B-5 is not submitted.
Yes. The S:z:c %rnisI:zz waiver servic:~to i::c'i-~::!uals 2 tile specir; ho:.:e an:: cc:.mun~:;.-hased ~~//ri;ler
group under 42 CFR 5435.217.
Select one and comnplete Appendix B-5.
All individuals in the special home and community-based weiver group under 42 CFR §435.2'!7
Appendix B: Waiver NY.0034.RO6.02 - Jul02,2012
Page 9 of 24
Only the following groups of individuals in the special home and community-based waiver group
under 42 CFR 3435.217
Check each that applies:
A special income level equal to:
Select one:
300% of the SSI Federal Benefit Rate (FBR)
A percentage of FBR, which is lower than 300% (42 CFR 9435.236)
Specify percentage:
A dollar amount which is lower than 300%.
Specify dollar amount:
Aged, blind and disabled individuals who meet requirements that are more restrictive than the
SSI program (42 CFR 9435.121)
Medically needy without spenddown in States which also provide Medicaid to recipients of SSI (42
CFR 5435.320, $435.322 and 9435.324)
Medically needy without spend down in 209(b) States (42 CFR 3435.330)
Aged and disabled individuals who have income at:
Select one:
100% of F'PL
% of FPL, wbich is lower than 100%.
Specify percentage amount:
Other specified groups (include only statutory/regulatory reference to reflect the additional
groups in the State plan that may receive services under this waiver)
h e n d- i x B: Participant Access and Eligjbilli-Q
-.B-5:Post-Eligibility Treatment (4; income (1 of4)
-.-
In accol-dmzce with 42 CFR $441.303(e), Appendix B-5 must be complefedwhei.! [heState furnisher ivaiver services to
individuals in the special home and commurzi&-based waivci g;.oup under 42 CFi? $435.21 7, as irLicated in Appenclii B-4.
Post-eligibiliv applies a:;iy lo the 42 CFR $435.21 7 group. A E!c!c that uses spczsal impoverisk::;~;:.!
I-zllesunder j1924 of the
Act to determine the eligibiliiy of individu~lswith a commurzi~spozise may eleci to use spousa1pos:-eligibility rules' undei'
$1924 of the Act to protect a personal needs allowance for apnr.Ncipant with a community spouse.
a. Use of Spousal Imp3verisIimee'i Rules. Indicate whether spousal impovei.ishment rules are used to determine
eligibility for the special home and community-based waiver group under 42 CFR $435.217 (select one):
Ans:vers provided in Appendix B-4. icdicate that you do not ~ c e d
to subrnit Appendix E-5 and therefore tlais
scstion is not visihle.
Appendix B: Participant Access and Eligibility
R-5: Post-Eligibility ~ r e a t m e n of
t Income (2 of 4)
Appendix B: Waiver NY.0034.RO6.02 - Jul02,2012
Page 10 of 24
b. Regular Post-Eligibility Treatment of Income: SSI State.
Answers provided in Appendix B-4 indicate that you do not need to submit Appendix B-5 and therefore this
section is not visible.
Amendix B: Partici~antAccess and Eli~ibilitv
B-5: Post-Eligibility Treatment of Income (3 of 4)
c. Regular Post-Eligibility Treatment of Income: 209@) State.
Answers provided in Appendix B-4 indicate that you do not need to submit Appendix B-5 and therefore this
section is not visible.
Appendix B: Participant Access and Eligibility
B-5:Post-Eligibility Treatment of Income (4 of 4)
d. Post-Eligibility Treatment of Income Using Spousal Impoverishment Rules
The State uses the post-eligibility rules of §1924(d) of the Act (spousal impoverishment protection) to determine the
contribution of a participant with a community spouse toward the cost of home and community-based care if it
determines the individual's eligibility under $1924 of the Act. There is deducted from the participant's monthly income
a personal needs allowance (as specified below), a community spouse's allowance and a family allowance as specified
in the State Medicaid Plan.. The State must also protect amounts for incurred expenses for medical or remedial care (as
specified below).
Answers provided in Appendix B-4 indicate that you do not need to submit Appendix B-5 and therefore this
section is not visible.
Appendix B: Participant Access and Eligibility
B-6: Evaluation/Reevaluation of Level of Care
As speciJied in 42 CFR §441.302(c), the State provides for an evaluation (andperiodic reevaluations) of the needfor the level
(s) of care specifiedfor this waiver, when there is a reasonable indication that an individual may need such services in the
near future (one month or less), but for the availability of home and community-based waiver services.
a. Reasonable Indication of Need for Services. Ln order for an individual to be determined to need waiver services, an
individual must require: (a) the provision of at least one waiver service, as documented in the service plan, and (b) the
provision of waiver services at least monthly or, if the need for services is less than monthly, the participant requires
regular monthly monitoring which must be documented in the service plan. Specify the State's policies concerning the
r e t ~ s o i ~ ~indicatio:?
ble
l;i't!lc need for zrvices:
i. Minimum nr:_::cr of service-.
The minimum i:zinber of waivr: r::l/ices (one or r;:n~e) that an inii-!i-!:;a1 must requiv: i ; order
~
to be
determined ta need waiver servic::: is: 1
iI, Frequency of services. The State requires (select one):
The provision of wriver ser-!ices at least mor:thly
Monthly monitoring of the individual when services are furnizhed on a less than monthly basis
lJcrheState alro requires a mir7imunt$~equencyjli.i. the provision of waivei. scrvices other than irionthiy
(e.g.,quarterly), spec~JLthefiequency:
b. Responsibility for Performing Evaluations and Rcevaluations. Level of care evaluations and reevaluations are
performed (select one):
Appendix B: Waiver NY.0034.RO6.02 - Jul02,2012
Page 11 of 24
Directly by the Medicaid agency
By the operating agency specified in Appendix A
By an entity under contract with the Medicaid agency.
SpeciJL the entity:
Other
SpecrJL:
The LOC evaluations and reevaluations are performed by a NYS licensed Registered Nurse(RN) from the
LTHHCP agency or the facility from which the applicantlparticipant is being discharged or the individual's
attending physician.
c. Qualifications of Individuals Performing Initial Evaluation: Per 42 CFR §441.303(~)(1),specify the
educational/professional qualifications of individuals who perform the initial evaluation of level of care for waiver
applicants:
The DMS-1 and the Pediatric PRI are the tools used for the initial evaluation and reevaluation of LOC. The DMS-I
and Pediatric PRI must be a face to face assessment which is completed by a NYS licensed Registered Nurse (RN) or
physician, or a facility RN if the individual is hospitalized or residing in a nursing facility at the time of evaluation.
d. Level of Care Criteria. Fully specify the level of care criteria that are used to evaluate and reevaluate whether an
individual needs services through the waiver and that serve as the basis of the State's level of care instrument/tool.
Specify the level of care instrument/tool that is employed. State laws, regulations, and policies concerning level of care
criteria and the level of care instrument/tool are available to CMS upon request through the Medicaid agency or the
operating agency (if applicable), including the instrument/tool utilized.
A physician or RN must complete the New York State Long Term Care Placement Form Medical Assessment
Abstract (DMS-1) and the Pediatric PRI. The DMS-1 and Pediatric PRI are the instruments used to evaluate an
individual's cun-ent medical condition. To ensure accurate completion of the LOC evaluation, NYSDOH issued
written guidelines for the DMS- I assessment tool in the LTHHCP Reference Manual released to LDSSs and
LTHHCP agencies in August 2006. The LDSS staff reviews 100% of all DMS-1 and Pediatric PRI forms submitted
for applicants/participants. If there appear to be discrepancies in the documentation or scoring, the LDSS staff
confers with the LTHHCP agency to discuss and resolve all identified issues. If agreement is not reached, the LDSS
local professional director reviews the case and makes the final decision regarding the issue. NYSDOH waiver
management staffprovides technical assistance as needed and reviews the DMS- I or Pediatric PRI upon request by
either party to assist in resolving disagreements.
A DMS-I score of 60 or greater indicates an individual is eligible for nursing facility care. An indicator score of 60179 equates to a proxy calculation for a lower level of care (historically referred to as Health Related Facility
(HRF)). A score greater than 180 indicates a Skilled Nursing Facility (SNF) level of care. Expenditure caps are
calculated at 50%, 75%, and 100% of HRF or SNF. The individual expenditure cap is calculated using thc average
nursing facility rate in the county of residence. This cost control mechanism provides cost neutrality assurance.
Policy allo\vz 1: local profession;.! director or oLl:;. designated phYicisil of the api;:i:::.:: gparticipant's chsice to
provide overridcjastification ofthe indicator score li:i;its when an individual does no"Lc,:ie a minimum of 50 on the
DMS-1. The written physician oveiride justificatio~~
must include, but is not limited tc, tl?!: medical, psychssocial,
andlor rehabi1i;cli-ye needs which would othenvizc i.;;r:ire an indivir;t:5 to be instilz:ic::,,:ised if it were [;st for the
LTHHCP services.
e. Level of Care Hnstrument(s). Per 42 CFR §441.303(~)(2),indicate whether the instrumeilt/tool used to evaluate level
of care for the wciver differs from the instnrment/tool used to evaluate institutional leve! of care (select one):
The same instrument is used in determining the level of care for the waiver and for institutional care under
the State Plan.
A different i n s t r u ~ c n tis usec! to determine the leve! of care for the waiver. that: for instiilrtional cnre undci
the State plan.
Describe how and why this instrument differs fiom the form used to evaluate institutional level of care and
explain how the outcome of the determination is reliable, valid, and fully coinparable.
Appendix B: Waiver NY.0034.RO6.02 - Jul02,2012
Page 12 of 24
The Patient Review Instrument (PRI) is the assessment tool used to evaluate whether an individual in need of
long term care services can be considered for home and community based services or whether nursing facility
(NF) placement is necessary, primarily due to a lack of informal caregivers needed to support the individual in
the home environment. The intent is to support the State's policy to maintain all appropriate individuals in the
least restrictive environment assuring that individuals can remain safely in their own home when possible with
appropriate long term care services. The next step in the evaluation process would then be to determine
eligibility for services based on whether the individual chooses to remain in hidher home and community or
wishes to seek NF placement.
The assessment tool used for determining LTHHCP eligibility is the DMS-I, which is comparable to the PRI in
the information it captures. The DMS-I had been the instrument used to evaluate eligibility for NF placement
prior to implementation of the PRI process. The DMS-1 was replaced with the PRI when the HRFISNF payment
levels were eliminated and payment was changed to resource utilization groups (RUGS). However, the
information collected on the PRI remained consistent with the information on the DMS-1, that is, identification
of medical conditions or diagnoses, medical nursing treatments needed, level of assistance needed with activities
of daily living (ADL), cognitive and behavioral needs and therapies needed. Individuals with minimal care
needs, that is, requiring some assistance with ADLs and having minimal cognitive impairment are those
individuals who would be eligible for NF placement but would fall into the lowest paying RUGS category with
the expectation that they would consume minimal amounts of NF staffing resources. Similarly, they are the
individuals that would score in the lower range of the DMS-1 tool as well. In NYS, both NFs and the LTHHCP
have patients that are at these minimal care needs as well as those having progressively higher needs.
To assure that the DMS- 1 is completed accurately, it is reviewed by the LDSS as part of the LTHHCP
authorization process and is also part of the case record review by NYSDOH waiver management staff. In
addition, NYSDOH surveillance staff review the DMS-I upon LTHHCP agency survey to assure that needs have
been identified, reflected on the plan of care, and consistent with the information on the DMS-I used for program
eligibility determinations.
The Pediatric PRI is the nursing facility assessment tool used for children under 18 years of age under New
York's Care at Home 1/11 Waiver.
f. Process for Level of Care Evaluation/Reevaluation: Per 42 CFR §441.303(c)(l), describe the process for evaluating
waiver applicants for their need for the level of care under the waiver. If the reevaluation process differs from the
evaluation process, describe the differences:
The LOC Evaluation/Reevaluation determinations are conducted by the State through its agents, the Local
Departments of Social Services (LDSS), which are assigned responsibility for the administration of the waiver under
State Statute. Responsibilities in this role include determination of the level of care for all applicants for whom there
is reasonable indication services may be needed and periodic redeterminations for participants according to approved
waiver procedures.
The LTHHCP waiver employs the current LOC instrument, the Long Term Care Placement Form Medical
Assessment Abstract (DMS-1) and the Pediatric Patient Review Instrument (PPRI) to determine a potential waiver
perticipant's initial level of carc znd redetermination.
I:: !he LTHMC;', :..I:icdividuals 71-7rrzessed for I:;.:(:::;
::ursing fz,:i:?v LOC upon r.;;,: I:::i?:?
into thi: :::'?:::'.m,
at
every 180 tic;;:.:after accep:::.; :-:into the prograi:: :.::ci more fic.-&-.
;.::$ as circumstil;:,: :; warrant scz:: :. : -.vher~a
..,-:river participan:: has experienced r:-,nificant changcs i l l health statvs, il:':!uding physicc?;,cognitive or bciir.-:ioral
s:c(us.
. .:: following s:-2;;s are taken:
..:st
r-.
To assess the individual, a licenscd medical professional examines/intcrviews/ assesses, in
face to face visit, the applicantlpa-ticipant. The licensed professional can be the
LTHHCP agency RN, the individuai's attending physician, or a facility
RN, if the individual is hospitalized or residing in a nursing facility at the time of
asseszment.
o The assessor completes the DMS- 1 or PPRi and signs attesting to the validity of the
assessment. It is then forwarded by the assessor to the LDSS.
o LDSS staff reviews the completed form to assure all sections are complete, the fox1 is
signed and dated appropriately, and all indicators are scored accurately. The LDSS staff
reviews 100% of all DMS-I and PPRI forms submitted for applicants/ participants.
o If there appear to be discrcpancies in the documentation or sco~ingof the DMS-I, or the
PPRI, the LDSS staff confers with the assessor to discuss and resolve all identifiec!
G
r!
I
Appendix B: Waiver NY.0034.RO6.02 - Jul02,2012
Page 13 of 24
issues. If agreement is not reached, the LDSS local professional director reviews the case
and makes final decision regarding the issue.
o NYSDOH waiver management staff provides technical assistance as needed and reviews the
DMS-I or PPRI upon request by either party to assist in resolving disagreements.
To promote accurate completion and scoring of the LOC assessment, NYSDOH issued written guidelines for the
DMS-I assessment tool in the LTHHCP Reference Manual which was released to LDSSs and LTHHCP agencies in
August 2006.
g. Reevaluation Schedule. Per 42 CFR $441.303(~)(4),reevaluations of the level of care required by a participant are
conducted no less frequently than annually according to the following schedule (select one):
Every three months
Every six months
Every twelve months
Other schedule
SpecrJj, the other schedule:
Every 180 days
h. Qualifications of Individuals Who Perform Reevaluations. Specify the qualifications of individuals who perform
reevaluations (select one):
The qualifications of individuals who perform reevaluations are the same as individuals who perform initial
evaluations.
The qualifications are different.
Specrb the qualrfications:
L
2
r-7
PA
i. Procedures to Ensure Timely Reevaluations. Per 42 CFR §441.303(~)(4), specify the procedures that the State
employs to ensure timely reevaluations of level of care (specrJL):
NYSDOH waiver management staff specifically monitors LOC determination by the DMS-I and PPRI forms in a
random case record review to assure:
o Timeliness of LOC determination
o Completion of the entire instrument
o Accuracy in scoring
o Appropriate signatures and dates
o A score of 60 or higher on the DMS-I, as evidence the individual meets NF eligibility
criteria or completed PPRI showing the medical needs of an individual under 18 years of age
o When a physician override is used, in the case of an individual's predictor score not
reflecting the true status with regard to the level of care required, the written physician
override justification must include, but is not limited to, the medical, psychosocial,
and/or rehabilitative needs which would othe~wiserequii-c an individual to be
institutionalized if it were not for the L'TI-IHCP services.
j. M::i::??::~zce of Eliz1:rr5i?n/Reeva1r1r.':;:::!?...cords. PC: 42 CFR $441.3CL;?:)$j, the State ;-rsl~r!:s that writte:: L:!:/O!eleciic:!ice!ly retrievi.:;: :rlocumentatio;l i:ycl! $valuatic::.; ::.:,I reeveluatioiis :I-:;xzintainec: i'. ::: ::~inirrlumpe1.i:::: 5'3
years es required in 45 CFR 592.42. Speci$ the location(:;) \:!?ere records of cvnluations and rcc:~~luations
of level of
care a x ~iiaintained:
The LDSS and the L714:-:2P agency arc 20th responsible fc: :?:e safe retenti:;i of all records fo: :..least three (3)
years. The records will bc maintained in both agencies ensuring that they will be readily retrievable if requested by
CMS or the NYSDOH VJziver Management Staff.
Appendix B: Evaluation/Reevaluation of Level of Care
Quality Hnnprovemerl: Levebof Care
As a disti17ct component of the Strrte 's quality improvement strate_q, provide infoi.~nationin thefollowiizgfields to detail the
State's nzethodsfor discovery and remediatio~~.
a. Methods for Discovery: Level of Care Assurance/Z:nb-assurances
i. Su b-Assurances:
Appendix B: Waiver NY.0034.RO6.02 - Jul02,20 12
Page 14 of 24
a. Sub-assurance: An evaluation for LOC is provided to all applicantsfor wlrom there is reasonable
indication that services may be needed in thefuture.
Performance Measures
For each pet$ormance measure/indicator the State will use to assess compliance with the statutory
assurance complete thefollowing. Wherepossible, include numerator/denominator.Each performance
measure must be specific to this waiver (ie., data presented must be waiver speciJic).
For each performance measure, provide information on the amrenated data that will enable the State
to analyze and assess prowess toward the performance measure. In this section provide information on
the method by which each source of data is analyzed statistically/deduc~ivelyor inductively, how themes
are identified or conclusions drawn, and how recommendations are formulated, where appropriate.
Performance Measure:
Number and percentage of all new enrollees who have a level of care indicating
need for nursing facility level of care, prior to receipt of services.
Data Source (Select one):
Other
If 'Other' is selected,-specify:
. LDSS Case Records
Sampling Approach
(check each that applies):
100% Review
Agency
Operating Agency
Monthly
Sub-state Entity
Quarterly
Less than 100%
Review
I
i
i
1
Representative
Sample
Confidence
Interval =
95%
Random
sample
statevlidc of
375 ccxc rccord
revic.:/s
annc- : ' ; I :-.:d
addiii~:::::
record:;
revie:.:ocl r.r,
needed ::
monitor Icsal
district a116
provider
verforrnance5%
Stratified
Describe
Group:
Ex
-1
r 1
I .-I
Appendix B: Waiver NY.0034.RO6.02 - Jul02,2012
Page 15 of 24
Continuously and
Ongoing
Other
Specify:
52
r- 'I
P :,,I
Other
Specify:
52
F
b. Sub-assurance: Tlte levels of care of enrolledparticipanfs are reevaluated at least annually or a.v
specified in tlte approved waiver.
Performance Measures
For each yerfbrmance tneasure/indicator h e State will use to assess colj~pliancewith the staluloly
rr:.:u;.o;?cecon2pletc t,':~:,fo!lo~vitg.
Wl:?repossible, ir?c!::rl.:
:r:r!:zei.ntor/rlc::o~;~!;~ator.
Each!i8~ij<:;.::!oi7ce
... ..... ...:c
..
,..
must be S~~CC;'.';: io ihis wai:. . . 5'..., da./npres~;::::..7::irr,-i
be wa;:..
:
.y;.sciJic).
Fa:.
-,.
:!I perforrnm7c.-:r.r-osure, -pro~-'J;
' -Srmation c;z
I*:!!
~ w e p a t e dr',-',- ,"dwill enable :.'r
State
to cr;^nlv.~e
and assess nL9gres.s towar.&,'_? r:nrforn?ancelgzoeztre. In this~e~ib?:?
urovide infoi~~i~ciion
on
the
I : . -/iod I;v which r:rrclz source o f datr :.anolyzed stof!.-iicallv/deductivel.:
,..-.ind~ctiveh~.
,'-o;v themes
.
are id:?ntifiedor conclusions drawiz, and /;owrecommei~ciationsare formulated where apPpr.opriale.
PerCc -:masce Measurc:
Number and percentage of enrolled wr?!ver partieipznts who are reevaluzted a t
least every 180 days (or lrore frequentIjr as circumstances warrant)
Datc Source (Select one):
O"r1er
If 'Other' is selected, specify:
LDSS Case Records
he'ip:N170.107.1 CO.99/WMCl~~.~.sss/protected/35/~~rint/Prin'iZelcr,tor.jsp
Appendix B: Waiver NY.0034.RO6.02 - Jul02,2012
Page 16 of 24
Responsible Party for
Weekly
100% Review
Operating Agency
Monthly
Less than 100%
Review
Sub-state Entity
Quarterly
Representative
Sample
Confidence
Interval =
95%
Random
sample
statewide of
375 case record
reviews
annually and
additional
records
reviewed as
needed to
monitor local
district and
provider
performance
1
Other
Specify:
Annually
Stratified
Describe
Group:
r
$
F-.
52
PI
k:..!
-~
~
Continuously and
Ongoing
I
I
Other
Specify:
!
Data Aggregation and Analysis:
Respczzi>le P21.i;~for datz
aggregation azc! analysis (check each
that applies):
State r,*'iedicaidAgency
I
Operating Agency
E
r
-1
t' '
I
4-
L rcquency cf data aggrega:ion ar:C
analysis (check each that applies):
I
V!eekly
Monthly
I
Appendix B: Waiver NY.0034.RO6.02 - Jul02,2012
Responsible Party for data
aggregation and analysis (check each
that applies):
Page 17 of 24
Frequency of data aggregation and
analysis (check each that applies):
Sub-State Entity
Quarterly
Other
Specify:
Annually
52
r- I
t,.A
Continuously and Ongoing
Other
Specify:
2
F 1
t. .'I
c. Sub-assurance: The processes and instruments described in the approved waiver are applied
appropriately and according to the approved description to determine participant level of care.
Performance Measures
For each pei$ormance measure/indicator the State will zise to assess compliance with the statutoty
assurance complete thefollowing. Wherepossible, include numerator/denominator. Each performance
measure must be specific to this waiver (i.e., data presented must be waiver specific).
For each performance measure. provide information on the annregated data that will enable the State
to analyze and assess urogress toward the performance measure. In this section provide information on
the method b y which each source o f data is analvzed statistically/deductivefv or inductively, how themes
are identified or conclusions drawn, and how recommendations are formulated, where appropriate.
Performance Measure:
Number and percentage of LOC determinations made by qualified evaluator
Data Source (Select one):
Other
If 'Other' is selected, specify:
LDSS Case Record
Pesponsible Party for
Freqarenr-y of dais
Sampling A?y-oach
clsrta
coil :c:io:;/generatio::
(check eaciz t!;nt applies):
collectionlgenerotlon
(cireck each that applies):
+/!eck each t1;r: c;:.!c.~):
..-.
-.
.
G;:IP.\",-ly
. , ..
j
100% R,.::I.:-,Y
State Mediccis
/I
Agency
I . . __
- -. .:
.-.
~-..
-.:, :!..
-
1
/
--
-
-
-.
~
Operatin2 /;gency
i?'::
Sub-state Entity
Qu:-::berly
-
:
-
;:jiy
.~.
....
Less tha:: 1:. 3%
Review
RepresentrCive
!
Confidence
Interva! =
95%
Random
sample
statewide of
375 case record
Appendix B: Waiver NY.0034.RO6.02 - Jul02,2012
Page 18 of 24
reviews
annually and
additional
records
reviewed as
needed to
monitor local
district and
provider
performance.
Other
Specify:
Annually
Stratified
Describe
Group:
52
FT
F.x+'
52
;1
Continuously and
Ongoing
Other
Specify:
52
r
1
I' :
I
Other
Specify:
P"-
$4
t.:
Data Aggregation and Analysis:
Responsible Party for data
aggregation and analysis (check each
that applies):
Frequency of data aggregation and
analysis (check each that applies):
State Medicaid Agency
Weekly
Operating Agency
Monthly
Sob-State Entity
-----
-.
.*-----.-...-
,.~
- . .
Other.
p..
L
.,..";:
:
I- -
-.
Quarterly
.-- .
?"----
Annually
,. . . )
----
-.-
---.
. .--
-*t
L .i..
7 . 7 z e . :-
--.. =--.....
.
'--.--.II
~1Continuous:;
:-
.
,
3n~iling
. ~..
I
Other
Specie:
Fr?rforrnr.:!ce Measure:
D!amBer 2nd percenta~sof EOC dc:-srrninrtion (initial z:?d aannal) made ora the
State's approved form.
Data Source (Selec; one):
OtI1.r
Page 19 of 24
Appendix B: Waiver NY.0034.RO6.02 - Jul02,2012
Responsible Party for data
aggregation and analysis (check each
that applies):
Page 20 of 24
Frequency of data aggregation and
analysis (check each that applies):
Operating Agency
Monthly
Sub-state Entity
Quarterly
Other
Specify:
Annually
z2
r-7
I:tl
Continuously and Ongoing
Other
Specify:
52
K;
Performance Measure:
Number and percentage of LOC criteria that was applied correctly.
Data Source (Select one):
Other
If 'Other' is selected, svecifv:
LDSS Case ~ e c o r d 's -
Agency
Operating Agency
Monthly
Sub-state Entity
Quarterly
Less than 100%
Review
Representative
Sample
Confidence
Interval =
95%
,. -.,.~
. ..>.V
s::.;:pie
s!e:ewide of
3'75 case record
,.
, ~-./ ; e w s
annually and
additional
records
reviewed as
needed to
ma;:itor IocaI
district and
provider
pel-formance.
Specify:
Stratified
I
I
I
Appendix B: Waiver NY.0034.RO6.02 - Ju102,2012
Page 2 1 of 24
52
I
Describe
Group:
~1
k
2.l
52
r
--I
b.4
Continuously and
Ongoing
Other
Specify:
ZZ
r-l
F.2.1
Other
Specify:
FT
F?
b :.-
Data Aggregation and Analysis:
Responsible Party for data
aggregation and analysis (check each
that
...... aonlies):
--rr- - --,
State Medicaid Agency
Frequency of data aggregation and
analysis (check each that applies):
Weekly
Operating Agency
Monthly
I
Sub-state Entity
Quarterly
Annually
Other
Specify:
52'
r-1
P." ! I
I
Continuously and Ongoing
Other
Specify:
ii. T1':..:,,iicable, in ti: I '::::>ox belov,~:,l:l-i;-.;I '-, :;y nece::
.:,'.ditional inC::: :;.::,::? on the st:-'-:-.':semployee! :-;
thc I::zir: to disc~?:i:i:.:.:~tifV ~roblernc1::;nes within ;:;, :.;ver mogram, i::.:r;din fiecll: ;::nd pa-ties
resi)wsible.
Se11c:r.l strategies 2:;~
cxployed:
-.-.I
NYSDOH surveillance staff monitors all LTHHCP agencizs that operate in New York State by standard
periodic inspections ti::?.; include state certification survey:;, federal initial certification survey: end
receriification surveys ;o ensure thc agerlcy meets federal (Pdedicare) and State regulations, kl:ich govern
them. LTHHCP agencies are surveyed at a maximum intelval of 36 months to determine the quality of care
and services furnished by the agency as measured by indicators of medical, nursing and rehabilitative care.
In accordance with protocols clevelopec! pursuant to the Dcpartmeni's Quality Management Action Plsn, all
significant issues/deficiencies identifiec! by NYSDOI-1 surveillance staff during survey 01. by complaint
investigation are shared on a monthly basis with NYSDOIH waiver mar.sgernent staff.
I
In addition to the annual case record reviews, NYSDOH waiver management staff also monitors LOC
adequacy during the LDSS administrative reviev,~~.
Appendix B: Waiver NY.0034.RO6.02 - Jul02,20 12
Page 22 of 24
b. Methods for Remediationmixing Individual Problems
i. Describe the State's method for addressing individual problems as they are discovered. Include information
regarding responsible parties and GENERAL methods for problem correction. In addition, provide information
on the methods used by the State to document these items.
Several methods are employed:
When a survey identifies regulatory requirements have not been met, the deficiency is identified to the
LTHHCP agency operator in a written report to which the LTHHCP agency operator must respond with a
corrective action plan. A plan of correction(s) must be submitted by the LTHHCP agency operator for each
deficiency cited. The plan of correction is reviewed and accepted by NYSDOH based on remediation of the
deficiency(s).
NYSDOH waiver management staff will notify the LDSS contact in the affected district of issues discovered
through NYSDOH survey and complaint processing that would require investigation or intervention with the
LTHHCP participant who may be at risk. NYSDOH waiver management staff provides necessary follow
upltechnical assistance. A summary of issues identified, remediation and follow up will be maintained in the
Technical Assistance database and be tracked and trended.
When problems are discovered from the annual case record reviews or during the LDSS administrative
reviews conducted by NYSDOH waiver management staff, further investigation and remediation actions will
be triggered. Problem findings identified are discussed with LDSS program staff and provided in a written
report to the LDSS Commissioner and subsequent case record review is planned for evidence of compliance
with remediation.
NYSDOH waiver management staff will convene as needed regional meetingslfocus groups with LDSS staff
and LTHHCP agencies to discuss identified issues and potential solutions.
ii. Remediation Data Aggregation
Remediation-related Data Aggregation and Analysis (including trend identification)
Frequency of data aggregation and analysis
Responsible Party (check each that applies):
(check each that applies):
I
State Medicaid Agency
Weekly
Operating Agency
Monthly
Sub-state Entity
Quarterly
Other
Specify:
Annually
52
F -1
b. 4
c. TimeIlnes
When the State does not hr!c all elements ofthe Quality Imprc-xment Strategy in place, provide li!:.ielines to design
methods for discovery and .?mediation related to the assurancc ~f Level of Care that are currently ::?n-operational.
No
Yec
Please provide a detailcd stratcgy for assuring Level of Care, the q;ecific tiincline for implementing ic!cntified
strategies, and the parties responsible for its operation.
In accordance with the CMS Quality Assurance Review Action Plan submitted by DOH:
An electronic uniform assessment tool has bee11identified for use in NYSDOH long--:-em home and conmunity
based services and is expected to be phased in during State fiscal year 201 1-2012 for rile LTHHCP. This project
is being coordinated by the Division of Policy and Planning within tlie Office of Long Term Care.
Appendix B: Waiver NY.0034.RO6.02 - Jul02,2012
Page 23 of 24
The Office of Long Term Care has a current initiative under way to develop a uniform data set and has
identified many sources of data elements. The uniform data set development project is complete and resulted in
the identification of an electronic uniform assessment tool. This project is coordinated by the Division of Policy
and Planning within the Office of Long Term Care.
DOH waiver management staff has met with data management staff to begin identifying potential data sources
to be used in creating quarterly management reports with key variables such as participant enrollment,
expenditures, service utilization. The NYSDOH Home Health and Hospice Profile website has been identified
as a data source for information regarding LTHHCP agency's services provided, counties served, inspection
reports, enforcement actions that may have been taken against the agency and quality measure performance
rankings.
The agenda for the October 2008 LTHHCP Technical Assistance Group conference call included discussion
regarding LDSS input of ongoing tracking, reporting elements, and data gathering in relation to LOC;
specifically, the development of a required tracking system for use by the LDSS to include processing
information related to length of time between the application and LOC assessment/reassessment, for assurance of
compliance with timeliness. A follow up discussion and draft process was reviewed in January 2009 for
expected implementation by early 2009.
NYSDOH waiver management staff developed and implemented the LDSS' tracking system. Quarterly
submission of LDSS data reports began in July 2009 and are ongoing.
Appendix B: Participant Access and Eligibility
B-7: Freedom o.f Choice
Freedom of Choice. As provided in 42 CFR §441.302(d), when an individual is determined to be likely to require a level of
carefor this waiver, the individual or his or her legal representative is:
i. informed of anyfeasible alternatives under the waiver; and
ii. given the choice of either institutional or home and communi&-based services.
a. Procedures. Speci@ the State's procedures for informing eligible individuals (or their legal representatives) of the
feasible alternatives available under the waiver and allowing these individuals to choose either institutional or waiver
services. Identify the form(s) that are employed to document freedom of choice. The form or forms are available to
CMS upon request through the Medicaid agency or the operating agency (if applicable).
The LTHHCP waiver recognizes its responsibility to inform potential waiver participants of their right to Freedom of
Choice. The LDSS, in the initial meeting with the potential waiver participant, informs himlher that they have a
choice between living in a nursing home or living in the community supported by available services and supports,
including services available through this waiver. Each potential waiver participant signs a Freedom of Choice form
sigilifying hislher prcltrcnce.
b. R'iain'ienance of Forms. Per 45 CFR 592.42, written copies or electronically retrievable facsimiles of Freedom of
C::~1~forms
,7
are li:rinhined for a rni.;i:-,:.::-.: of three JG:-:s. C-~ecifythe Ir ?::i.:.!r,
vhere cc:;izc ?'these fornir.:.::
ForI:: _:iaiver partici:::::; who have ckl::c:-. waiver ser-.+::.: ::xd have txi: :;;:.wed to pz:.:l:::: ..:s in the v!.lri-~c:
proy::n, copies of thl: ,:.:npleted Freedc~.:,?
of Choice f~i.::-::?:ill be maintaincc! for at least tl!i.?: !3) years in thc :.GSS
cass yccord.
A endix B: Participavf Access an!=bility
.
A
B-8: Access to Services by Limited Eng-ish Proficiency Persons
-
Accsys io Services by !!!irnited 3nglicl: ?;.oficient :3ersons. SpeciLy the n;e-kods that d e State uses to provicic i:~daningCi!!
access to the waiver by Limited English Proficient persons in accordance vlith the Department of Health and Human Services
"Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination
Affecting Limited English Proficient Persons" (68 FR 473 11 - August 8,2003):
Potential and active waiver participants wit11 limited fluency in English must have access to services without undue
hardship. LDSSs must have arrangements to provide interixetation or translation services for pctential and active waiver
participants who need them. This is accomplished through a variety of means including; employing bi-lingual staff, resources
Appendix B: Waiver NY.0034.RO6.02 - Jul02,2012
Page 24 of 24
from the community (e.g. local colleges) and if necessary contracting with interpreters. Those who are non-English speaking
may bring a translator of their choice with them to meetings with waiver providers and/or the LDSS. However, they may not
be required to bring their own translator, and no person can be denied access on the basis of a LDSS's inability to provide
adequate translations.